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Position Statement 49: Perinatal Mental Health

Policy

A major component of health care reform in the United States is the imperative to deal with our appallingly high infant mortality rates and the evidence they reveal of a medical care system that is failing to meet the needs of parents and very young children. As of 2011, the U.S. ranked 34th in the world, with 6.9 infant deaths per 1,000 live births, twice the infant mortality of Singapore, Iceland or Japan.[1]

Better infant care is essential, and about half of these deaths occur during the birthing process and within 28 days postpartum, but most care of babies takes place in the home, and the care of a nurturing family can easily be compromised by mental health conditions that may surface when a child is born. Help with parenting, as well as timely individual mental health treatment as needed, are both important to address this sobering failure and the toll that perinatal mental health conditions take on American babies, mothers, fathers, and the entire family unit.

Prevention, screening and treatment can be effective in lessening the symptoms of perinatal mood and anxiety disorders and the resulting impact on American families.[2] Mental Health America (MHA) believes that a comprehensive system of prevention, outreach and response should be developed that responds to this need.

Background

Postpartum depression is the most common complication after childbirth.[3] Symptoms may develop during pregnancy and include depressive or anxious features such as: persistent sadness and hopelessness, inability to accept comfort or love, social withdrawal, feeling overwhelmed, lacking in energy, emptiness, fatigue, changes in sleeping and eating patterns, crying episodes, guilt, anxiety, panic attacks, frustration, and irritability. Onset is usually from three weeks to four months after birth but can occur at any time during the first year and often lasts for a year or more if untreated. Perinatal mood and anxiety disorders greatly compromise parenting.

Women are more likely to develop depression and anxiety during the first year after childbirth than at any other time.[4] Studies report prevalence rates among women of from 5% to 25%, or higher in adolescents and some ethic groups, but methodological differences among the studies make the actual prevalence rate unclear.

Perinatal mental health disorders are much broader than depressive symptoms alone, though too often the term “postpartum depression” is used to generalize these conditions. The spectrum of disorders includes:

Antenatal depression and anxiety

Postpartum depression and anxiety

Postpartum anxiety/panic disorder

Postpartum obsessive compulsive disorder

Postpartum post-traumatic stress disorder

Postpartum psychosis.

Pre-existing mental health disorders may be exacerbated by pregnancy and childbirth. Diverse strategies are thus needed to address mental health symptoms that may be intensified by the immense physical, psychological, and situational adjustments that occur during the perinatal period.

Only 40% of mothers with perinatal mood and anxiety disorders seek treatment.[5] Consequences for the mother and infant can be long term and life-threatening, and may lead to severe emotional problems and general medical problems in mothers, fathers and children if early appropriate treatment is not received.

Postpartum psychosis is a distinct disorder that may be erroneously referred to as postpartum depression. It is less common, occurs within the first two weeks after delivery, and is a medical emergency. Symptoms may include thought disturbances, delusions, hallucinations and disorganized speech or behavior. The prevalence of postpartum psychosis in the general population is one per 1,000 childbirths.6 Bipolar disorder and schizophrenia appear to be closely correlated to an elevated prevalence of postpartum psychosis, so careful monitoring of mothers with pre-existing conditions can provide timely diagnosis and treatment, thus improving outcomes for mothers and infants.

Causes of perinatal mood and anxiety disorders appear to be multifactorial. The most likely hypothesis is that mental health changes are triggered by the significant changes in a woman's hormones during pregnancy.7 Yet other studies have suggested there is no known correlation between hormones and postpartum mood and anxiety disorders, and hormonal treatment has not helped those experiencing such disorders. Sleep deprivation may play an important role in the severity of symptoms that may begin during pregnancy due to hormonal and other changes in the mother’s body and worsen after birth due to the demands of caring for an infant.8

Further, fathers, who are not undergoing profound hormonal changes, suffer perinatal mood disorders at relatively high rates. During the first postpartum year, the incidence of paternal depression ranged from 1.2% to 25.5% in community samples, and from 24% to 50% among men whose partners were experiencing perinatal mood disorders. Maternal depression was identified as the strongest predictor of paternal depression during the postpartum period.9

Antenatal depression, also known as prenatal depression, can be a precursor to postpartum depression if not properly treated. It is estimated that 7% to 20% of pregnant women are affected by this condition. Any form of prenatal stress felt by the mother can have negative effects on various aspects of fetal development, which can cause harm to the mother and child. Commonly, symptoms involve how the patient views herself, how she feels about going through such a life changing event, the restrictions on the mother's lifestyle that motherhood will place, or how the partner or family feel about the baby. Pregnancy puts a lot of strain on a woman's body, so some stress, mood swings, sadness, irritability, pain, and memory changes are to be expected. Antenatal depression may lead to pre-eclampsia in pregnant women, preterm birth, and low birth weight infants with ongoing complex health needs.10

MHA has previously endorsed the 2009 Institute of Medicine report on prevention of mental health and substance disorders in young people.11 In the same year, the IOM issued a companion report that found that universal screening is beneficial during pregnancy and during the first twelve months after birth but only if mental health service follow-up is readily available.12 Perinatal mood and anxiety disorders can be treated with a variety of approaches including social support, lifestyle modifications, talk therapy, and medications.13

Screening is successful with any of several instruments; however, the PHQ-9 and the Edinburgh Postnatal Depression Scale (EPDS) are the most frequently used by clinicians. These screens can be completed by the mother in any healthcare setting and reviewed by the health care provider for immediate follow-up by mental health care providers.14

Call To Action

Screening for perinatal mood and anxiety disorders and follow up care should be a required element as part of cost effective health home and general medical and mental health integration in all health plans.

Screening may take place in mental health settings, obstetrical care settings, pediatric care settings, WIC offices or occupational health settings. Education about postpartum depression and about healthy parenting should be provided with screening.

Mental health professionals should be co-located within the settings where screening is preformed to provide immediate evaluation, diagnosis, and treatment of mothers with positive screening results. This approach will reduce barriers to care, improve compliance, and provide the best outcomes for mothers and infants. Where physical co-location is not feasible, virtual co- location by telehealth is a reasonable alternative.

Most mothers are in the workforce so it is especially important that employers have occupational health programs to prevent and identify perinatal mood and anxiety disorders among employees, and provide support, accommodations, and referrals when needed.

Education about and resources for perinatal mood and anxiety disorders should be provided not only in the workplace but also during prenatal care, postpartum care, pediatric health care visits, and at discharge from hospitals after childbirth.

As mandated by the Affordable Care Act, “more research is needed on causes and incidence rates, differences in racial and ethnic groups, improved screening and diagnosis, and the development of new treatments” for perinatal mood and anxiety disorders.15

Effective Period

The Mental Health America Board of Directors adopted this policy on September 15, 2013. It will remain in effect for a period of five (5) years and is reviewed as required by the Mental Health America Public Policy Committee

12. Institute of Medicine, Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention, Committee on Depression, Parenting Practices, and the Healthy Development of Children, Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press, 2009.